Method and apparatus for coupling anatomical features

ABSTRACT

A method of coupling a first portion of an anatomy to a second portion of the anatomy includes coupling first and second bones of the anatomy with a bone-tendon-bone implant. The bone-tendon-bone implant has a first bone end, a second bone end and a replacement tendon between the first and second bone ends. The first and second bone ends are positioned in corresponding first and second bores of the first and second bones. The first bone end is secured to the first bone with a first bone anchor. A second anchor coupled to the bone-tendon-bone implant is passed through and outside the second bore. The second anchor is coupled to an adjustable suture construct having two adjustable suture loops. Tensioning at least one of first and second ends of the adjustable suture construct tensions the replacement tendon and positions the first bone relative to the second bone.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. patent application Ser. No.13/412,116 filed on Mar. 5, 2012, which is a divisional of U.S. patentapplication Ser. No. 12/196,407 filed on Aug. 22, 2008, now U.S. Pat.No. 8,137,382 issued on Mar. 20, 2012, which is a continuation-in-partapplication of: (1.) U.S. patent application Ser. No. 11/541,506 filedon Sep. 29, 2006, now U.S. Pat. No. 7,601,165 issued Oct. 13, 2009; (2.)U.S. patent application Ser. No. 12/014,399 filed on Jan. 15, 2008, nowU.S. Pat. No. 7,909,851 issued Mar. 22, 2011; (3.) U.S. patentapplication Ser. No. 12/014,340 filed on Jan. 15, 2008, now U.S. Pat.No. 7,905,904 issued Mar. 15, 2011; (4.) U.S. patent application Ser.No. 11/935,681 filed on Nov. 6, 2007, now U.S. Pat. No. 7,905,903 issuedMar. 15, 2011; (5.) U.S. patent application Ser. No. 11/869,440 filed onOct. 9, 2007, now U.S. Pat. No. 7,857,830 issued Dec. 28, 2010; (6.)U.S. patent application Ser. No. 11/784,821 filed on Apr. 10, 2007; (7.)U.S. patent application Ser. No. 11/347,661 filed on Feb. 3, 2006, nowU.S. Pat. No. 7,749,250 issued Jul. 6, 2010; and (8.) U.S. patentapplication Ser. No. 11/347,662 filed on Feb. 3, 2006, now abandoned.The disclosures of the above applications are incorporated herein byreference.

FIELD

The present disclosure relates to a method and apparatus for stabilizingtissue and, more particularly, to a method of coupling soft tissue to abone and for stabilizing anatomical features.

BACKGROUND

The statements in this section merely provide background informationrelated to the present disclosure and may not constitute prior art.

It is commonplace in arthroscopic procedures to employ sutures andanchors to secure soft tissues to bone. Despite their widespread use,several improvements in the use of sutures and suture anchors may bemade. For example, the procedure of tying knots may be very timeconsuming, thereby increasing the cost of the procedure and limiting thecapacity of the surgeon. Furthermore, the strength of the repair may belimited by the strength of the knot. This latter drawback may be ofparticular significance if the knot is tied improperly as the strengthof the knot in such situations may be significantly lower than thetensile strength of the suture material.

To improve on these uses, sutures having a single preformed loop havebeen provided. FIG. 1 represents a prior art suture construction. Asshown, one end of the suture is passed through a passage defined in thesuture itself. The application of tension to the ends of the suturepulls a portion of the suture through the passage, causing a loop formedin the suture to close. Relaxation of the system, however may allow aportion of the suture to translate back through the passage, thusrelieving the desired tension.

It is an object of the present teachings to provide an alternativedevice for anchoring sutures to bone and soft tissue. The device, whichis relatively simple in design and structure, is highly effective forits intended purpose.

SUMMARY

To overcome the aforementioned deficiencies, a method for configuring abraided tubular suture and a suture configuration are disclosed. Themethod includes passing a first end of the suture through a firstaperture into a passage defined by the suture and out a second aperturedefined by the suture so as to place the first end outside of thepassage. A second end of the suture is passed through the secondaperture into the passage and out the first aperture so as to place thesecond end outside of the passage.

A method of surgically implanting a suture construction into a tunnelformed in a bone is disclosed. A suture construction is formed bypassing the suture through a bore defined by a locking member. A firstend of the suture is passed through a first aperture within the sutureinto a passage defined by the suture and out a second aperture definedby the suture so as to place the first end outside of the passage anddefine a first loop. A second end of the suture is then passed throughthe second aperture into the passage and out the first aperture so as toplace the second end outside of the passage, and define a second loop.The first and second ends and the first and second loops are then passedthrough the tunnel. Soft tissue is then passed through the first andsecond loops. Tension is applied onto the first and second ends toconstrict the first and second loops about the soft tissue.

In another embodiment, a method of surgically implanting a suture isdisclosed. The suture is passed through a bore defined by a firstfastener. A suture construction is formed by passing the suture througha bore defined by a locking member. A first end of the suture is passedthrough a first aperture within the suture into a passage defined by thesuture and out a second aperture defined by the suture so as to placethe first end outside of the passage and define a first loop. A secondend of the suture is then passed through the second aperture into thepassage and out the first aperture so as to place the second end outsideof the passage, and define a second loop. A second fastener is coupledto at least one of the first and second loops. After the fastener iscoupled to the patient, tension is applied onto the first and secondends to constrict at least one of the first and second loops.

In another embodiment a method of surgically implanting a soft tissuereplacement for attaching two bone members is disclosed. First andsecond tunnels are formed in first and second bones. A pair of lockingmembers having a first profile which allows insertion of the lockingmembers through the tunnel and a second profile which allows engagementwith the positive locking surface upon rotation of the locking membersis provided. The suture construction described above is coupled to thelocking members. The first and second ends and the first and secondloops of the construction and the locking member are threaded throughthe first and second tunnels. Tension is applied to the sutureconstruction to engage the locking members and pull the first and secondbones together.

In another embodiment a method of coupling a first portion of an anatomyto a second portion of the anatomy is disclosed. The method includescoupling first and second bones of the anatomy with a bone-tendon-boneimplant. The bone-tendon-bone implant has a first bone end, a secondbone end and a replacement tendon between the first and second boneends. The first and second bone ends are positioned in correspondingfirst and second bores of the first and second bones. The first bone endis secured to the first bone with a first bone anchor. A second anchorcoupled to the bone-tendon-bone implant is passed through and outsidethe second bore. The second anchor is coupled to an adjustable sutureconstruct having two adjustable suture loops. Tensioning at least one offirst and second ends of the adjustable suture construct tensions thereplacement tendon and positions the first bone relative to the secondbone.

In another embodiment, a method of manufacturing an adjustable constructfor coupling a first portion of an anatomy to a second portion of theanatomy is disclosed. A suture having a body portion with a longitudinalinternal bore is passed through a bore of an anchor. The suture iscoupled to a fastener. A first end of the suture is passed through afirst aperture defined by the body portion of the suture and into thelongitudinal internal bore and out a second aperture defined by the bodyportion of the suture to form a first adjustable loop. A second end ofthe suture is passed through a third aperture defined by the bodyportion of the suture and into the longitudinal internal bore and out afourth aperture defined by the body portion to form a second adjustableloop.

Further areas of applicability will become apparent from the descriptionprovided herein. It should be understood that the description andspecific examples are intended for purposes of illustration only and arenot intended to limit the scope of the present disclosure.

DRAWINGS

The drawings described herein are for illustration purposes only and arenot intended to limit the scope of the present disclosure in any way.

FIG. 1 represents a prior art suture configuration;

FIGS. 2A and 2B represent suture constructions according to theteachings;

FIG. 3 represents the formation of the suture configuration shown inFIG. 2A;

FIGS. 4A and 4B represent alternate suture configurations;

FIGS. 5-7 represent further alternate suture configurations;

FIG. 8 represents the suture construction according to FIG. 5 coupled toa bone engaging fastener;

FIGS. 9-11B represent the coupling of the suture construction accordingto FIG. 5 to a bone screw;

FIGS. 12A-12E represent the coupling of a soft tissue to an ACLreplacement in a femoral/humeral reconstruction;

FIGS. 13A-13D represent a close-up view of the suture shown in FIGS.1-11C;

FIGS. 14-18 represent fasteners used in the teaching herein;

FIG. 19 represents the preparation of the femoral and humerus accordingto the teachings herein;

FIGS. 20 and 21 represent suture constructions;

FIGS. 22A through 22D represent the use of the suture construction ofFIG. 21 to couple a soft tissue construction to a femoral/humeraltunnel;

FIGS. 23 and 24 represent the coupling of soft tissue to an ulna;

FIG. 25 represents the coupling of soft tissue to a humerus; and

FIGS. 26-28 represent the stabilization of bony structures utilizingsuture constructions taught herein.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is notintended to limit the present disclosure, application, or uses. Itshould be understood that throughout the drawings, correspondingreference numerals indicate like or corresponding parts and features.

FIG. 2A represents a suture construction 20 according to the presentteachings. Shown is a suture 22 having a first end 24 and a second end26. The suture 22 is formed of a braided body 28 that defines alongitudinally formed hollow passage 30 therein. First and secondapertures 32 and 34 are defined in the braided body 28 at first andsecond locations of the longitudinally formed passage 30.

Briefly referring to FIG. 3, a first end 24 of the suture 22 is passedthrough the first aperture 32 and through longitudinal passage 30 formedby a passage portion and out the second aperture 34. The second end 26is passed through the second aperture 34, through the passage 30 and outthe first aperture 32. This forms two loops 46 and 46′. As seen in FIG.2B, the relationship of the first and second apertures 32 and 34 withrespect to the first and second ends 24 and 26 can be modified so as toallow a bow-tie suture construction 36. As described below, thelongitudinal and parallel placement of first and second suture portions38 and 40 of the suture 22 within the longitudinal passage 30 resiststhe reverse relative movement of the first and second portions 38 and 40of the suture 22 once it is tightened.

The first and second apertures are formed during the braiding process asloose portions between pairs of fibers defining the suture 22. Asfurther described below, the first and second ends 24 and 26 can bepassed through the longitudinal passage 30 multiple times. It isenvisioned that either a single or multiple apertures can be formed atthe ends of the longitudinally formed passage.

As best seen in FIGS. 4A and 4B, a portion of the braided body 28 of thesuture 22 defining the longitudinal passage 30 can be braided so as tohave a diameter larger than the diameter of the first and second ends 24and 26. Additionally shown are first through fourth apertures 32, 34,42, and 44. These apertures can be formed in the braiding process or canbe formed during the construction process. In this regard, the apertures32, 34, 42, and 44 are defined between adjacent fibers in the braidedbody 28. As shown in FIG. 4B, and described below, it is envisioned thesutures can be passed through other biomedically compatible structures.

FIGS. 5-7 represent alternate constructions wherein a plurality of loops46 a-d are formed by passing the first and second ends 24 and 26 throughthe longitudinal passage 30 multiple times. The first and second ends 24and 26 can be passed through multiple or single apertures defined at theends of the longitudinal passage 30. The tensioning of the ends 24 and26 cause relative translation of the sides of the suture 22 with respectto each other.

Upon applying tension to the first and second ends 24 and 26 of thesuture 22, the size of the loops 46 a-d is reduced to a desired size orload. At this point, additional tension causes the body of the suture 22defining the longitudinal passage 30 to constrict about the parallelportions of the suture 22 within the longitudinal passage 30. Thisconstriction reduces the diameter of the longitudinal passage 30, thusforming a mechanical interface between the exterior surfaces of thefirst and second parallel portions as well as the interior surface ofthe longitudinal passage 30.

As seen in FIGS. 8-11, the suture construction can be coupled to variousbiocompatible hardware. In this regard, the suture construction 20 canbe coupled to an aperture 52 of the bone engaging fastener 54.Additionally, it is envisioned that soft tissue or bone engaging members56 can be fastened to one or two loops 46. After fixing the boneengaging fastener 54, the members 56 can be used to repair, forinstance, a meniscal tear. The first and second ends 24, 26 are thenpulled, setting the tension on the loops 46, thus pulling the meniscusinto place. Additionally, upon application of tension, the longitudinalpassage 30 is constricted, thus preventing the relaxation of the tensioncaused by relative movement of the first and second parallel portions38, 40, within the longitudinal passage 30.

As seen in FIGS. 9-11B, the loops 46 can be used to fasten the sutureconstruction 20 to multiple types of prosthetic devices. As describedfurther below, the suture 22 can further be used to repair and couplesoft tissues in an anatomically desired position. Further, retraction ofthe first and second ends allows a physician to adjust the tension onthe loops between the prosthetic devices.

FIG. 11b represents the coupling of the suture construction according toFIG. 2B with a bone fastening member. Coupled to a pair of loops 46 and46′ is tissue fastening members 56. The application of tension to eitherthe first or second end 24 or 26 will tighten the loops 46 or 46′separately.

FIGS. 12A-12E represent potential uses of the suture constructions 20 inFIGS. 2A-7 in an ACL repair. As can be seen in FIG. 12A, thelongitudinal passage portion 30 of suture construction 20 can be firstcoupled to a fixation member 60. The member 60 can have a first profilewhich allows insertion of the member 60 through the tunnel and a secondprofile which allows engagement with a positive locking surface uponrotation. The longitudinal passage portion 30 of the suture construction20, member 60, loops 46 and ends 24, 26 can then be passed through afemoral and tibial tunnel 62. The fixation member 60 is positioned orcoupled to the femur. At this point, a natural or artificial ACL 64 canbe passed through a loop or loops 46 formed in the suture construction20. Tensioning of the first and second ends 24 and 26 applies tension tothe loops 46, thus pulling the ACL 64 into the tunnel. In this regard,the first and second ends are pulled through the femoral and tibialtunnel, thus constricting the loops 46 about the ACL 64 (see FIG. 12B).

As shown, the suture construction 20 allows for the application of forcealong an axis 61 defining the femoral tunnel. Specifically, theorientation of the suture construction 20 and, more specifically, theorientation of the longitudinal passage portion 30, the loops 46, andends 24, 26 allow for tension to be applied to the construction 20without applying non-seating forces to the fixation member 60. As anexample, should the loops 24, 26 be positioned at the member 60,application of forces to the ends 24, 26 may reduce the seating forceapplied by the member 60 onto the bone.

As best seen in FIG. 12C, the body portion 28 and parallel portions 38,40 of the suture construction 20 remain disposed within to the fixationmember 60. Further tension of the first ends draws the ACL 64 up throughthe tibial component into the femoral component. In this way, sutureends can be used to apply appropriate tension onto the ACL 64 component.The ACL 64 would be fixed to the tibial component using a plug or screwas is known.

After feeding the ACL 64 through the loops 46, tensioning of the endsallows engagement of the ACL with bearing surfaces defined on the loops.The tensioning pulls the ACL 64 through a femoral and tibial tunnel. TheACL 64 could be further coupled to the femur using a transverse pin orplug. As shown in FIG. 12E, once the ACL is fastened to the tibia,further tensioning can be applied to the first and second ends 24, 26placing a desired predetermined load on the ACL. This tension can bemeasured using a force gauge. This load is maintained by the sutureconfiguration. It is equally envisioned that the fixation member 60 canbe placed on the tibial component 66 and the ACL pulled into the tunnelthrough the femur. Further, it is envisioned that bone cement orbiological materials may be inserted into the tunnel 62.

FIGS. 13A-13D represent a close-up of a portion of the suture 20. As canbe seen, the portion of the suture defining the longitudinal passage 30has a diameter d₁ which is larger than the diameter d₂ of the ends 24and 26. The first aperture 32 is formed between a pair of fiber members.As can be seen, the apertures 32, 34 can be formed between two adjacentfiber pairs 68, 70. Further, various shapes can be braided onto asurface of the longitudinal passage 30.

The sutures are typically braided of from 8 to 16 fibers. These fibersare made of nylon or other biocompatible material. It is envisioned thatthe suture 22 can be formed of multiple type of biocompatible fibershaving multiple coefficients of friction or size. Further, the braidingcan be accomplished so that different portions of the exterior surfaceof the suture can have different coefficients of friction or mechanicalproperties. The placement of a carrier fiber having a particular surfaceproperty can be modified along the length of the suture so as to placeit at varying locations within the braided constructions.

FIGS. 14-18 represent various fasteners which can be used with thesuture constructions of FIGS. 1-7. FIG. 14 represents an elongatedanchor 70 defining a suture accepting bore 72. As described below, theanchor 70 has a first profile 79 which allows the anchor 70 to be passedthrough a bore defined in a bone. The anchor 70 can be rotated so as tohave a second profile 74 to allow engagement with a patient. Thefastener 70 has a tissue engaging surface 76 which is configured toengage either soft tissue or bone. Examples of this can be found in theform of a toggle lock in co-assigned and co-pending U.S. patentapplication Ser. No. 10/864,900, incorporated herein by reference.

As shown in FIGS. 15 and 16, the fasteners 78 and 80 can have agenerally cylindrical body 82 defining a through bore 84. Disposedacross the through bore 84 is a transverse pin 86 which is configured toslidably bear the suture construction. Optionally, the fastener can havean outer engagement rib or flange 83 which is configured to engage theperiphery of an aperture formed in the bone. The cylindrical body 82 canhave an outside diameter which is less than the diameter of the bore inthe bone.

As shown in FIGS. 17 and 18, the fasteners 90 and 92 can have a generalplanar button configuration having a plurality of suture acceptingthrough bores 93. These bores 93 can slidably or fixably accept thesuture 22. The button can have a diameter greater than the diameter ofthe tunnel formed in the bone. It is envisioned the fasteners 90 and 92can have flat or curved bearing surfaces. In this regard, the bearingsurface of the fasteners 90 and 92 can have a convex bearing shape.

FIGS. 19-22B represent the use of the suture construction to couple abone-tendon-bone graft construction 100 within a femoral/tibial tunnel102. As shown in FIG. 19, the tunnel 99 can have a first portion 103with a first diameter 107 and a second portion 109 having second smallerdiameter 108 within the femur. As described below, the second diameter108 can be used to couple the bone-tendon-bone construction 100 to thetunnel.

As shown in FIGS. 20 and 21, a loop of suture 96 is passed through acollapsible tube 98. The collapsible tube or a pair of loops formed by asuture 22 is positioned within the bore 72 of a first fastener 70. Asdescribed above, the collapsible tube 98 can be a portion of the suture22, or can be a separate member.

As seen in FIG. 21, to form the suture construction 73, the suture 22 ispassed through the first bore 72 defined by the first fastener 70. Thesuture 22 can then be passed through a second bore defined by a secondfastener 70 or a suture loop 77. In any of the embodiments, thecollapsible tube 98 can be a portion of the suture. A first end 26 ofthe suture 22 is passed through a first aperture 34 defined by thecollapsible tube 98 into a passage portion 30 defined by the collapsibletube 98 and out a second aperture 36 defined by the collapsible tube 98so as to place the first end outside of the passage portion 30 and forma first loop. A second end 26 of the suture 22 is passed through thesecond aperture 36 into the passage portion 30 and out the firstaperture 34 so as to place the second end 26 outside of the passageportion 30 and form a second loop 47. At this point, the passage portion30 can optionally be positioned within the first bore 72 of the fastener70 or the loop of the suture 22.

As seen in FIGS. 22A and 22B, the construction 73 is coupled to abone-tendon-bone construction 100 using the loop of suture 77 or afastener. The bone-tendon-bone implant 100 can be formed of anallograph-tendon construction or artificial bone-tendon orbone-tendon-bone prosthetic assembly. It is envisioned the physician canintraoperatively determine the desired graft or graft assembly lengthand appropriate graft tension.

After fixing the suture construction to the bone-tendon-boneconstruction 100 by for example a through pin 111, the bone-tendon-boneconstruction 100 is installed into the tunnel 102 formed in a femur andtibia 104, 105. As described above with respect to FIG. 12A, the sutureconstruction 73 of FIG. 21 can be fed through the femoral tunnel 102.The bone-tendon-bone construction 100 is then put into the tunnel 102. Afirst portion 106 of the bone-tendon-bone construction 100 is coupled toa tibial tunnel using a fastener 101 positioned within the tunnel. Asecond portion of the bone-tendon-bone construction 100 is pulled taughtinto the femoral tunnel by tensioning the ends 24 and 26 of the sutureconstruction 73. The portion 113 of the bone-tendon-bone construction100 can be coupled to the femur using a transverse or parallel boneengaging screw 101.

As seen in FIGS. 22C and 22D, a pair of suture constructions 22 and 22′are coupled to a pair of soft tissue replacements 64 and 64′ using theloops of suture 77, 77′ or a fastener. The pair of soft tissuereplacements 64 and 64′ can be formed of artificial of harvested tendonmaterial. It is envisioned the physician can intraoperatively determinethe desired graft or graft assembly length and appropriate grafttension.

After fixing the suture constructions 22 and 22′ to a toggle lock (seeFIG. 22D) and the pair of soft tissue replacements 64 and 64′ areimplant into the tunnel 102 formed in a femur and tibia 104, 105. Asdescribed above with respect to FIG. 12A, the suture constructions 22and 22′ of FIG. 21 can be fed through the femoral tunnel 104. The pairof soft tissue replacements 64 and 64′ are then pulled into the tunnel104 by applying tension onto the ends 24-26′ of the sutureconstructions. A first portion 106 of the pair of soft tissuereplacements 64 and 64′ is coupled to a tibial tunnel 105 using afastener 101 such as a WASHERLOK™ tibial fixation as provided by BiometSports Medicine positioned within the tunnel. A second portion of thepair of soft tissue replacements 64 and 64′ is pulled taught into thefemoral tunnel by tensioning the ends 24 and 26 of the sutureconstruction 73. The portion 113 of the pair of soft tissue replacements64 and 64′ can be coupled to the femur using a transverse or parallelbone engaging screw 101. It is envisioned the suture ends 24 and 26 canbe passed though a medial portal 25 to facilitate the tensioning of thepair of soft tissue replacements 64 and 64.

Alternatively, after insertion into the femoral tunnel 102, as seen inFIG. 12B, an appropriate amount of tension is applied to the pair ofsoft tissue replacements 64 and 64′ by applying tension to the ends 24and 26 of the suture construction. A fastener 101 is engageably drivenbetween the ends of pair of soft tissue replacements 64 and 64′ and theinternal surface of the bore formed in the tibia. This locks the pair ofsoft tissue replacements 64 and 64′ to the bone.

FIG. 23 represents the coupling of a flexor tendon 110 to the humerus.Shown is the ulna 112 having a through bore 114. The through bore 114can accept the suture construction 73 shown in FIG. 21. As describedabove with respect to the ACL replacement shown in FIG. 12A, the sutureconstruction 73 is fed through the tunnel 114 formed in the ulna 112. Asoft tissue graft 110 is fed through the pair of loops 46, 47 formed bythe suture construction 73. The ends 24, 26 of the suture 22 are thenpulled so as to pull the soft tissue graft 110 to or into the tunnel114. A second end of the soft tissue graft 118 can be coupled to a bore120 formed in a lateral epicondyle 122 of the humerus. A soft tissueengaging fastener 101 can be used to couple a soft tissue 110 to thebore 120. After engagement of the soft tissue fastener 101, the tensionof the soft tissue 110 can be adjusted by the tensioning of the sutureconstruction 73.

Similarly, as shown in FIG. 24, the bicep brachii tendon 130 can becoupled to the ulna 112 using the suture construction 73 shown in FIG.21. In this regard, a bore 114 is formed in the ulna. The fixationmember 70 is then positioned or coupled to the ulna 112. At this point,a natural or artificial bicep brachii tendon 130 can be passed through aloop or second fastener 70 or the loops 46, 47 formed in the sutureconstruction 73. Tensioning of the first and second ends 24 and 26applies tension to the loops 46, 47, thus pulling the tendon 64 to orinto the bore 114. The constricting the loops 46,47 then fasten thebicep brachii tendon 130 to the ulna 112. It is envisioned a bonecoupling fastener 101 can be used to fix the soft tissue 130 to theulna.

FIG. 25 shows the coupling of soft tissue 140 to the head of thehumerus. Defined in the humerus is a bore 114 configured to support thesuture construction 73. This bore can further have a transverse passage134. The transverse passage 134 can have at least one loop of the sutureconstruction 73 disposed therethrough so as to allow the coupling ofsoft tissue to or through the transverse passage 134. The longitudinalpassage portion 30 of suture construction 73 can be first coupled to afixation member 70. The member 70 has a first profile which allowsinsertion of the member 70 through the tunnel and a second profile whichallows engagement with a positive locking surface upon rotation. Thelongitudinal passage portion 30 of the suture construction 73, member70, loops 46 and ends 24, 26 can then be passed through the tunnel.

The fixation member 70 is positioned or coupled to the humeral head. Atthis point, a natural or artificial bicep tendon 140 can be passedthrough a loop or loops formed in the suture construction 73. Tensioningof the first and second ends 24 and 26 applies tension to the loops,thus pulling the tendon 140 to or into the transverse passage 134. Inthis regard, the first and second ends are pulled through the tunnel114, thus constricting the loops about the tendon 140 and pulling thetendon 140 or soft tissue to the transverse tunnel 134. Optionally, asoft tissue fastening screw can be used to fix the tendon 140 to thetransverse passage 134.

As shown in FIGS. 26-28, the suture construction 73 as shown in FIGS.1-7 can be used to couple and position bony elements of a patient. FIG.26 shows the coupling of a coracoid process 137 to the spine of scapula139. In this regard, a pair of coaxial bores 138 and 140 are formedwithin the coracoid process 137 and spine of scapula 139. A pair ofanchors 70, such as those shown in FIGS. 14-18, are coupled to a sutureconstruction 73 such as the one shown in FIG. 2A or 4A. A first fastener70 is fed through the aperture formed in the spine of scapula while thesecond fastener 70′ is fed through the bore 140 formed in the coracoidprocess 137. Tension is applied to the ends 24 and 26 of the sutureconstruction 73, pulling the bony structures into proper position. Thesuture construction of FIGS. 1-7 allow for the alignment compressionand/or positioning of the bone elements without the need to form knots.

Similarly, as shown in FIG. 27, the lunate 142 and scaphoid 144 can bedrawn together using the construction 73 shown in FIG. 26. In thisregard, it is envisioned that both the lunate 142 and scaphoid 144 canhave appropriate bores 138 and 140 formed therein. These bores acceptthe suture construction 73 as shown in 26 to allow stabilization of thepatient's anatomy.

As shown in FIG. 28, the radius 146 and ulna 148 can be coupled togetherby the use of a pair of axial suture accepting passages 138 and 140. Inthis configuration, the suture construction uses a first fastener 70which is configured to pass through the passages 138 and 140.Additionally, the fastener 92 shown in FIG. 18 can be used as a loadbearing member and bear against the ulna 148 and the application oftension to the ends 24 and 26 of the suture construction 73 tightens thesuture construction and stabilizes the bones of the joint.

The description of the invention is merely exemplary in nature and,thus, variations that do not depart from the gist of the invention areintended to be within the scope of the invention. For example, any ofthe above mentioned surgical procedures is applicable to repair of otherbody portions. For example, the procedures can be equally applied to therepair of wrists, elbows, ankles, and meniscal repair. The suture loopscan be passed through bores formed in soft or hard tissue. It is equallyenvisioned that the loops can be passed through or formed around anaperture or apertures formed in prosthetic devices e.g. humeral, femoralor tibial stems. Such variations are not to be regarded as a departurefrom the spirit and scope of the invention.

What is claimed is:
 1. An adjustable suture system, comprising: anadjustable suture construct, the adjustable suture construct including afirst suture with a first free end and a second free end, the first freeend extending longitudinally through a first longitudinal passage in thefirst suture to form a first adjustable loop, the second free endextending longitudinally through a second longitudinal passage in thefirst suture to form a second adjustable loop, wherein, with the firstfree end extending longitudinally through the first longitudinal passagein the first suture to form the first adjustable loop, the first freeend can be pulled through the first longitudinal passage to decrease asize of the first adjustable loop, and wherein, with the second free endextending longitudinally through the second longitudinal passage in thefirst suture to form the second adjustable loop, the second free end canbe pulled through the second longitudinal passage to decrease a size ofthe second adjustable loop; a continuous suture loop formed separatelyfrom the adjustable suture construct yet coupled to the adjustablesuture construct, wherein the continuous suture loop being coupled tothe adjustable suture construct includes suture material along thecontinuous suture loop extending through the first adjustable loop andthrough the second adjustable loop proximate a first end of theadjustable suture construct; and a first bone engaging member coupled tothe adjustable suture construct proximate a second end of the adjustablesuture construct.
 2. The adjustable suture system of claim 1, whereinthe first longitudinal passage is separate from the second longitudinalpassage in the first suture.
 3. The adjustable suture system of claim 1,wherein the first free end can be pulled through the first longitudinalpassage to decrease a size of the first adjustable loop withoutdecreasing a size of the second adjustable loop and the second free endcan be pulled through the second longitudinal passage to decrease a sizeof the second adjustable loop without decreasing a size of the firstadjustable loop.
 4. The adjustable suture system of claim 1, wherein thefirst bone engaging member comprises a button.
 5. The adjustable suturesystem of claim 4, wherein the button includes at least three throughbores therein.
 6. The adjustable suture system of claim 1, wherein thefirst bone engaging member includes a through bore with a transversemember disposed across the through bore.
 7. The adjustable suture systemof claim 1, wherein the first bone engaging member has a first profileallowing the first bone engaging member to be passed through a bonetunnel, and wherein the first bone engaging member can be rotated fromthe first profile to a second profile allowing the first bone engagingmember to engage patient tissue outside the bone tunnel.
 8. Theadjustable suture system of claim 1, wherein the first bone engagingmember includes a cylindrical body with a flange extending therefrom. 9.An adjustable suture system, comprising: an adjustable suture construct,the adjustable suture construct including a first suture with a firstfree end and a second free end, the first free end extending into thefirst suture through a first aperture in the first suture,longitudinally within the first suture between the first aperture and afourth aperture in the first suture, and out of the first suture throughthe fourth aperture to form a first adjustable loop, the second free endextending into the first suture through a second aperture in the firstsuture, longitudinally within the first suture between the secondaperture and a third aperture in the first suture, and out of the firstsuture through the third aperture to form a second adjustable loop,wherein, with the first adjustable loop formed, the first free end canbe pulled to decrease a size of the first adjustable loop, and wherein,with the second adjustable loop formed, the second free end can bepulled to decrease a size of the second adjustable loop; a continuoussuture loop formed separately from the adjustable suture construct,wherein suture material along the continuous suture loop extends throughthe first adjustable loop and through the second adjustable loop tocouple the continuous suture loop to the adjustable suture constructproximate a first end of the adjustable suture construct; and a firstbone engaging member coupled to the adjustable suture constructproximate a second end of the adjustable suture construct.
 10. Theadjustable suture system of claim 9, wherein the first aperture, thesecond aperture, the third aperture, and the fourth aperture are allseparate apertures in the first suture.
 11. The adjustable suture systemof claim 9, wherein the first free end can be pulled to decrease a sizeof the first adjustable loop without decreasing a size of the secondadjustable loop and the second free end can be pulled to decrease a sizeof the second adjustable loop without decreasing a size of the firstadjustable loop.
 12. The adjustable suture system of claim 9, whereinthe first bone engaging member comprises a button.
 13. The adjustablesuture system of claim 12, wherein the button includes at least threethrough bores therein.
 14. The adjustable suture system of claim 9,wherein the first bone engaging member includes a through bore with atransverse member disposed across the through bore.
 15. The adjustablesuture system of claim 9, wherein the first bone engaging member has afirst profile allowing the first bone engaging member to be passedthrough a bone tunnel, and wherein the first bone engaging member can berotated from the first profile to a second profile allowing the firstbone engaging member to engage patient tissue outside the bone tunnel.16. The adjustable suture system of claim 9, wherein the first boneengaging member includes a cylindrical body with a flange extendingtherefrom.